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Roberts, Theresa 2'-O`1 N OF QUEENs5BUir�Y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director 4kk�dw d.fJ,�lyy Name ��i�� J�/9 /14 6�/� �S C a s e # Date of Cremation Time Cremation Started _��N] � Time Cremation Completed '3•c56 Type of Container ©)=- ,E-�,�y Remarks : _ / CR' ��M TOWN OF QUEENSBURY 13� PINE VIEW CEMETERY&CREMATORIUM Quaker Road, Queensbury, New York, 12804 Phone(518)Crematorium 745-4477 of no answer Cemetery 745-4476 AUTHORIZATION TO CREMATE The undersigned requests and authorizes Pine View Crematorium, in Accordance with and subject to its Rules and Regulations to Cremate the remains of: n h�Q o C, ZAP �-uJD �C Q (Name) (Sex) 11� - Ia I (Street) (City) (State) (zip) who died on 1 day of ' ' `c�- " 20 �J at (Place) (Addres ) Name and address of nearest relative or name of person Authorizing cremation: '—\�6AO V clv�-V� (Name) (Address) Relationship to the deceased Name of Funeral Home 1 � �` -� ) IMPORTANT: I represent that to the best of my knowledge, the deceased has or" r as n acemaker in his or her body. (Circle One) certify that I have the full power and authorization to arrange For the cremation of the remains and to direct the disposition of the cremated remains, that any personal possessions have either been removed or may be destroyed, and agree to protect, defend and save harmless Pine View Crematorium from any and.all claims and demands for loss or damages which may be made against them by reason of or connected with the cremation of said remains as directed, whether such claims or demands are or are not wholly groundless, false or fraudulent. ( i ess) (Address) ' (Signatur of Relcitive or egal Re nd Address)) Signed on this date: V BAN& DENNY FUNERAL SEM iCL 33 Qu"" QwmAx",New York 12804 (519)792-1114 "Customer's Designation of Intentions" Name of Deceased: Cremation: I (Scheduled Date) (Location) Manner of Disposition of Cremated Remains: XBurial at El Return to Family El Entombment at El Other (specify): I hereby designate the Disposition of Cremated Remains and acknowledge receipt of a copy of form. Oignature) (Printed Name) (Relationship to Deceased) (Address) (Telephone Numher) "Cremated Remains which shall not have been claimed within 120 days from the date of cremation may be disposed of by this firm by placement in a columbarium. i o.,�L^. Printed J(�ne of Funeral Director Y Sign of Funeral Director Date or Undertaker or Undertaker TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS Cremation: (Actual Date) (Location of Crematory) Disposition of Cremated Remains: (Manner of Disposition) (Location) (Date) Name of Person Making Disposition Signature Date #9 'WHITE:Funeral Home Copy YELLOW.Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96